Digestive and Liver Disease最新文献

Background: Autoimmune liver disease (AILD) encompasses autoimmune hepatitis (AIH), autoimmune sclerosing cholangitis (ASC) and primary sclerosing cholangitis (PSC). A unified disease process evolving over time through these entities has been recently suggested. From this perspective, this study aimed to compare the characteristics of childhood-onset AILD at baseline and after a medium-to-long term follow-up period.

Methods: Paediatric-onset cases of AILD diagnosed between 1992 and 2023 at a tertiary-care centre were reviewed. Patients transitioned to adult-care by the time of data collection were asked for clinical updates.

Results: Fifty-five patients were included (AIH = 20, ASC =22, PSC =13). AIH, ASC and PSC exhibited increasing age at the onset (AIH to PSC, p < 0.01). The area under the receiver operating characteristic curve for gamma-glutamyltranspeptidase (GGT) combined with alkaline phosphatase/aspartate aminotransferase (ALP/AST) ratio in predicting sclerosing cholangitis was 0.94, with a sensitivity of 86 % and a specificity of 94 %. At the last follow-up (median duration 5,8 years, interquartile range [IQR] 2,9-10,2, n = 45), 15 patients (33 %) developed portal hypertension, 2 patients (4 %) underwent liver transplantation, no patient died.

Conclusion: A cohort of childhood-onset AILD managed at a single centre reveals a temporal trend in the onset of AIH, ASC and PSC, with progressively older ages. Elevated GGT levels combined with a high ALP/AST ratio predict the diagnosis of sclerosing cholangitis. The occurrence of liver-related adverse events in one-third of patients highlights the progressive nature of paediatric-onset AILD.

Background: The role of various histologic scores in predicting outcomes in acute severe ulcerative colitis (ASUC) is unexplored.

Methods: Consecutive patients of ASUC undergoing sigmoidoscopy and histological assessment by two independent pathologists for Simplified Geboes score (SGS), Robarts Histopathology Index (RHI) and Nancy histological index (NHI)] were included. Primary outcome was the role of histology in predicting need for second-line therapy or colectomy.

Results: Of 82 patients with ASUC (mean age: 36 years, males 47.5 %), non-response to steroids was observed in 27 (32.9 %) of cases. Sixteen patients required second-line drug therapy and 8 required colectomy. There was no significant association between the need for second-line therapy or colectomy and the baseline histological scores [NHI (p = 0.61), SGS (p = 0.116) and RHI (p = 0.109)]. All three scores performed poorly to predict the need for second-line treatment or colectomy within 28 days. There was no significant association between histological scores and steroid response (NHI (p = 0.796), SGS (p = 0.57) and RHI (p = 0.941)]. All three scores had a strong positive correlation observed between each other but not with endoscopic Mayo score.

Conclusion: The three histologic scores (SGS, RHI and NHI) performed poorly in prediction of need for second-line treatment or colectomy in ASUC. Future studies should study the impact of histologic assessment on long term outcomes in ASUC.

Background and aim: Corpus atrophic gastritis (CAG) is defined as autoimmune when the antrum is spared, representing this element a crucial diagnostic criterium of autoimmune gastritis. In contrast, CAG with concomitant antral gastritis (AG), atrophic or non-atrophic, is generally attributed to H. pylori infection. During the natural history of CAG, possible antrum healing has been supposed. The current study aimed to assess the antral mucosa histopathological changes at long-term follow-up (FU) with respect to baseline in patients with CAG and concomitant atrophic or non-atrophic gastritis AG.

Methods: Retrospective study on 130 patients with histologically diagnosed CAG with atrophic or non-atrophic AG. Mean FU gastroscopy was at 40.6 (range 4-192) months. Patients with confirmed CAG (n = 117; median age 66, range 20-87 years; 67.5 % F) were finally included. At baseline, 47 (40.2 %) had non-atrophic and 70 (59.8 %) atrophic AG. Helicobacter pylori (Hp) infection was present at histology in 27.3 % of patients, all treated.

Results: At FU, 30/117(25.6 %) patients showed a complete antral healing; 11/29(37.9 %) were Hp positive at baseline, cured in all but one. Atrophic AG regressed in 16/70(22.8 %) patients. Both, antral healing and regression of antral AG, were found to be similar in Hp-cured and not-cured/ naïve-negatives patients (p > 0.05).

Conclusion: In a subset of CAG patients, AG may regress at long-term FU irrespective of Hp cure, thus mimicking autoimmune atrophic gastritis and raising concerns about its current histopathological diagnostic criteria.

Background: Available guidelines lack in indications on surgical standard in Ulcerative Colitis (UC) AIMS: To determine the role of surgical strategies of colectomy and proctectomy with pouch-anal-anastomosis (IPAA) on functional outcomes in a nationwide population multicenter study. The secondary aims consisted of perioperative outcomes and complications.

Methods: Data on 379 patients who underwent total abdominal colectomy and proctectomy with ileo-pouch-anal-anastomosis (IPAA) with or without diverting ileostomy were retrospectively collected in a red cap multicenter-database searching for variables that could impact on pouch outcomes as cuffitis, pouchitis, anastomotic stenosis, pouch stenosis, failure or pathological Low-Anterior-Resection-Syndrome (LARS) score.

Results: Mesocolic dissection sealing vessels at major trunks and from medial to lateral are associated with better outcomes. Laparoscopy is associated with lower rate of cuffitis over time (p = 0.028). Mesentery lengthening is associated with higher pouchitis rate (p = 0.015) and earlier failure (p < 0.0001). Hand-sewn IPAA results in early anastomotic stenosis (p = 0.00011). The Transanal-Transection and Single-Stapling Anastomosis (TTSS) showed to be protective against pouchitis. Extended dissection of adhesions correlates with lower rate of pouchitis-episodes (p = 0.0057).

Conclusions: The study highlights advantages of laparoscopy. New techniques such as TTSS promise further improvements. Mesentery lengthening correlates with high risk of pouch-failure and pouchitis, hand-sewn anastomosis increased risk of stenosis.

Background: Availability of liver transplantation (LT) as a treatment for hepatocellular carcinoma (HCC) and other liver malignancies may determine heterogeneity of therapeutic strategies across different centers.

Aims: To investigate the practice between hepato-biliary centers without (HB centers) and with a LT program (LT centers), we launched a 38-item web-based national survey, with directors of centers as a target.

Methods: The survey, including 4 clinical vignettes, collected data on their approach to HCC and transplant oncology.

Results: After duplicates removal, 75 respondents were considered. Respondents from LT centers (n = 22, 29.3 %) were more in favor of LT in the case of HCC outside Milan criteria (90.9 % vs. 67.9 %, p = 0.037), recurrent HCC (95.5 % vs. 50.9 %, p = 0.002) and other malignancies such as cholangiocarcinoma or neuroendocrine tumors. No significant difference was observed concerning the proportion of centers favorable to LT for unresectable colorectal liver metastases (100 % vs. 88.7 %, p = 0.100).

Conclusion: This national survey showed how management of HCC and awareness of transplant oncology may differ between HB and LT centers. Effective networking between HB and LT centers is crucial to provide optimal treatment and access to LT.

Aim: This study aimed to investigate the outcomes and effectiveness of various treatment strategies in patients with hepatic artery stenosis (HAS) after pediatric liver transplantation (pLT).

Methods: This is a single center observational cohort study between January 1st, 2004 and August 1st, 2023, including pLT recipients aged <18 years. The primary outcome was graft and patient survival. The secondary outcomes included incidence of biliary complications, technical success of surgery or endovascular therapy (EVT), and changes in liver function. The cut-off for early and late HAS was 14 days after pLT.

Results: Among a total of 327 pLT patients, 4 % (n = 13) developed HAS (n = 3 early; n = 10 late). Treatments included surgical revascularization for one early HAS, conservative management with anticoagulation for one early and four late HAS, and EVT for one early and six late HAS. Over a median follow-up of 28.2 months after the diagnosis of HAS, graft survival was 100 % and 83 % in early and late HAS groups, and patient survival reached 100 % in both groups. One graft loss occurred in the conservative group. Conversely, graft survival in the EVT group was 100 %.

Conclusion: The long-term outcomes of HAS after pLT are excellent. Both EVT and conservative management exhibited high graft survival rates for late HAS, with EVT achieving high technical success.

Background: There is limited comparative data on patients with inflammatory bowel disease (IBD) switched from intravenous to subcutaneous infliximab and those continuing intravenously. This study aimed to compare the persistence and tolerance of subcutaneous and intravenous infliximab and the outcomes of patients resuming intravenous infliximab.

Methods: We conducted a retrospective single-centre cohort study involving IBD patients treated with maintenance intravenous infliximab. The switch to subcutaneous infliximab was offered to patients in clinical remission receiving an intravenous dose ≤ 10 mg kg^-1 every ≥ 6 weeks. The switch group was compared to controls remaining on intravenous infliximab due to refusal of the switch.

Results: With a median follow-up of 59 (46-67) weeks, subcutaneous infliximab was discontinued in 28/282 (10 %) patients and intravenous infliximab in 1/78 (1 %) patient (p = 0.01); after propensity score-matching of the two cohorts, persistence rates at 52 weeks were respectively 91 % (95 % CI 84-98) and 100 % (95 % CI 100-100, p = 0.01). Among the 28 who discontinued subcutaneous infliximab, 27 resumed intravenous infliximab, with 4 (1 % of the switch group) who permanently stopped infliximab.

Conclusion: Switching from intravenous to subcutaneous infliximab led to a lower treatment persistance. In cases of poor tolerance or relapse under subcutaneous infliximab, resuming intravenous infliximab is effective.

Background: The presence of acute kidney injury (AKI) significantly increases in-hospital mortality risk for cirrhotic patients. Early prognosis prediction for these patients is crucial. We aimed to develop and validate a machine learning model for in-hospital mortality prediction for cirrhotic patients with AKI.

Methods: Data from cirrhotic patients with AKI hospitalized at the First Affiliated Hospital of Zhejiang University between January 1, 2013, and December 31, 2020 were used to train and validate an extreme Gradient Boosting model to predict in-hospital mortality risk. The Boruta algorithm was used for variable selection. The optimal model was selected and named as PHM-CPA (Prediction of in-Hospital Mortality for Cirrhotic Patients with AKI). The PHM-CPA model was then externally validated in patients from eICU Collaborative Research Database (eICU-CRD) and Medical Information Mart for Intensive Care III dataset (MIMIC). The predictive performance of PHM-CPA model was compared with that of logistic regression (LR) model and 25 previously reported models.

Results: A total of 519 cirrhotic patients with AKI were enrolled in model training cohort, of whom 118 (23%) died during hospitalization. Fifteen variables from common laboratory tests were selected to develop the PHM-CPA model. The PHM-CPA model achieved an AUROC of 0.816 (95% CI, 0.763-0.861) in the internal validation cohort and 0.787 (95% CI, 0.745-0.830) in the external validation cohort. The PHM-CPA model consistently outperformed the LR model and 25 previously reported models.

Conclusion: We developed and validated the PHM-CPA model, comprising readily available clinical variables, which demonstrated superior performance and calibration in predicting in-hospital mortality for cirrhotic patients with AKI.